Living Well Workshop Interest Form

*
1.Please provide the name of your organization or company.

*
2.Organization, Company or Facility Address

*
3.Please provide the name of the primary contact for your organization.

*
4.Please provide the primary contact person e-mail address.

*
5.Please provide the primary contact person's telephone number.

*
6.Please provide the primary contact person's fax number.

*
7.Which option best describes your organization or company type?

Academic Institution

Adult/Family Housing

Adult Daycare Center

Assisted Living Facility (ALF)

Community-based Organization

Company Worksite

Correctional facility or institution

Faith-based Organization

Free clinic

Library

Local Health Department (LHD)

Park and Recreation Center

Physical Rehabilitation Center

Senior Center

Senior Housing

Senior Living Community

Skilled Nursing Facility (SNF) or Long-term Facility (LTC)

YMCA

Other (please specify)

*
8.Please provide your "Living Well" workshop interest(s):

Stanford Chronic Disease Self-Management Program (CDSMP)

Stanford Diabetes Self-Management Program (DSMP)

Tomando Control de su Salud (Spanish version of CDSMP)

Both CDSMP and DSMP

*
9.Please provide your Organization’s preferred method for follow-Up

On-site presentation and visit

Informational session by telephone

Other (please specify)

*
10.To meet the needs of each organization, Living Well in Georgia workshops schedules (including start dates and times) and locations are coordinated with each interested organization. Please provide a preferred "Living Well" workshop start period (by month).

2014: January (mid)

2014: February (early)

2014: February (mid)

2014: March (early)

2014: March (mid)

2014: April (early)

2014: April (mid)

2014: May (early)

2014: May (mid)

2014: June (early)

2014: June (mid)

2014: July (early)

2014: July (mid)

2014: August (early)

2014: August (mid)

2014: September (early)

2014: September (mid)

2014: October (early)

2014: October (mid)

Unsure, to be determined.

Other (please specify)

*
11.Please provide a preferred day of the week for a "Living Well" workshop to be conducted on-site.

Friendly Reminder: Workshops would be conducted only one day each week for a period of 6 consecutive weeks.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

*
12.Please provide a preferred time frame for a "Living Well" workshop to be conducted on-site.

10 am-12:30 (lunchtime)

12:30-3 pm

3 pm-5:30 pm

Unsure at this time, to be determined.

Other (please specify)

*
13.Members of your organization or company are also welcome to receive free trainings to become "Living Well" program lay leaders. Please share if your organization's staff or volunteers are interested in participating in future Lay Leader trainings.